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'Please print as type.(Form designed for use on elite(12-pRch)typewriter.) Form Approved.OMB No.2050-0039 UNIFORM HAZARDOUS 1.Generator ID Number 2.Page 1 of 3 Emergency Response Phone 4.M(a�nifest T�racking Number WASTE MANIFEST 01 1J O 7.5 2 4 JJ K 5.Generators Name and Mailing Address .Generators SkeAddress Qf different than mailing address) Generators Phone: 6.Transporter 1 Company Name U.S.EPA ID Number 7.Transporter 2 Company Name U.S.EPA ID Number 8.Designated Facility Name and Site Address U.S.EPA ID Number Facility's Phone: - - ga, 9b.U.S.DOT Description(including Proper Shipping Name,Hazard Class,ID Number, 10.Containers 11.Total 12.Unit HM and Packing Group(if any)) 13.Waste Codes No. Type Duantity Wt.Nol. 7 1 o 4r zCD 2. W 3. I.Special Handling Instructions and A,1ddrtt7al Information 15. GENERATOR'SIOFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name,and are classified,packaged, marked and labeled/placarded,and are in all respects in proper condition for transport according to applicable intemational and national governmental regulations.If export shipment and I am the Primary Exporter,I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a)If I am a large quantity generator)or(b)(if I am a small quantity generator)is true, GeneratoeslOfferors Printedrryped Name Signature Month Day Year ..a16.International Shipments F ❑Import to U.S. ❑Export Som U.S Part of entrylexR Transporter signature(for exports only): Date leaving U.S.: W 17.Transporter Acknowledgment of Receipt of Materials Transporter 1 Printecirfyped Name Signature Month Day Year O ; ZQ Trensporter2 Pnntedrryped Name Signature:' Month Day Year K P- } 18,Discrepancy 18a.Discrepancy Indication Space ❑ Quantity ❑Type ❑Residue ❑Partial Rejection ❑Full Relection nk iv'bac q �, 186.Alternate Facility(or Generator) RE - ". 1!_,t U.S.EPA ID Number � LL FacilisPhone: MAY D i 2 0y W 18c.Signature of Ntemate Fadlity(or Generator) Month Day Year i �IViRONMENTAI H&^f_T�; PFMA `Hmrdous Waste Report Management Method Codes(i.e.,codes for hazardous waste treatment,disposal,and recycling sys ms)" G 2. 3. 4. 1 20.Designated Facility Owner or Operator:Certification of receipt of h nmmous materials covered by the manifest except as noted in Item 18a PrintedrTyped Name Signature Month Day Year EPA Form 8700-22(Rev.3-05) Previous editions are obsolete. GENERATOR'S INITIAL COPY